6,433 reports
Information drawn from published reports and official responses.
Ruth Milne was admitted with severe sepsis affecting both legs and died within 24 hours from multi-organ failure and septic shock. The report raised concerns about continuity of care, the appropriateness and expertise of staff attending before admission, and whether safeguarding action plans and recommendations had been implemented.
Lincolnshire Community Health Services NHS Trust
Stephen Leven, who had haemophilia, developed a headache and visual-field changes and was later found to have a large intracerebral haemorrhage. He died on 13 December 2016; the principal concern was that hospital clinicians lacked access to GP information about his haemophilia, which could contribute to deaths in similar future circumstances.
Department of Health and Social Care
Nature Barr, who was detained under the Mental Health Act 1983, was found collapsed and in cardiac arrest on 23 February 2016 and later pronounced deceased. The cause of death was unascertained; there was concern that Novel Psychoactive Substances may have caused or contributed to his death, although this could not be substantiated. The report also raised concern that there was no specific evidence that the associated risk was being addressed.
University of Hertfordshire
A fire broke out at 141 Manchester Road, Swindon, on 6 November 2016 after combustible materials were probably ignited by a bio ethanol heater. Sharon Ann Soares and Blaise Sanito Alvares were rescued but later died from injuries sustained in the fire. Evidence at the inquest indicated that this was at least the second occasion involving fatalities attributable to a bio ethanol burner, alongside previous accidental injuries.
National Fire Chiefs Council
A fire broke out at 141 Manchester Road, Swindon, on 6 November 2016 after combustible materials were probably ignited by a bio ethanol heater. Sharon Ann Soares and Blaise Sanito Alvares were rescued but later died from injuries sustained in the fire. Evidence at the inquest indicated that this was at least the second occasion involving fatalities attributable to a bio ethanol burner, alongside previous accidental injuries.
National Fire Chiefs Council
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
Bow SchoolBromley by Bow Health CentreCompass Wellbeing Tower HamletsDepartment of Health and Social CareLondon Ambulance Service NHS TrustRoyal London HospitalSteel's Lane Health CentreThe British Society For Allergy & Clinical Immunology
Richard Anthony Bull was discovered deceased by his wife in the bath at home, holding an iPhone connected to a charger plugged into a socket in the hall. The family expressed concern that phone chargers were not perceived as risky items when in contact with water and that warnings should be highlighted.
Apple (UK) Limited
Cedrick Sykers, a hemiplegic nursing-home resident who could not stand, reposition himself or propel his wheelchair, died in hospital after his clothes caught fire while he was smoking unsupervised in a garden. The report identified concerns about insufficient recognition and mitigation of the risks faced by immobile residents who smoke and cannot summon help, including the lack of clearly documented requirements for supervision, smoking aprons and alarm pendants.
BupaCare Quality CommissionLewisham Safeguarding Adults Board
David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.
Boldmere Court Care HomeCare Quality CommissionDepartment of Health and Social Care
Andrew Jonathan Wilson had end-stage renal failure managed with home peritoneal dialysis and was admitted to Maidstone Hospital with sepsis on 20 July 2015. Peritoneal dialysis was unavailable at Maidstone Hospital and its satellite renal unit for three nights before he was transferred to the Kent and Canterbury Hospital, where dialysis was recommenced. He later deteriorated and died of natural causes; concerns were raised about the lack of arrangements, trained staff, equipment, and clinician awareness needed to provide peritoneal dialysis outside the Canterbury renal unit.
East Kent Hospitals University NHS Foundation Trust
A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.
Care Quality CommissionManchester University NHS Foundation TrustNHS Greater Manchester Integrated Care Board
Mr Reginald Frank Lewis was admitted to hospital after a fall, later fell again while on Ward C19 and sustained a head injury causing an intracerebral bleed; he died on 17 January 2017. Concerns included inadequate communication of his confusion, falls risk and blindness during transfer, his being left unsupervised after family visitors left, and pressure to accept him into a ward already managing several patients requiring continuous observation.
Black Country Healthcare NHS Foundation TrustNew Cross Hospital
Muriel Ann Brett underwent aortic valve replacement surgery on 11 March 2016, followed by a second operation the next day. After three transoesophageal echocardiographs, an oesophageal perforation was identified on 20 March 2016, and she died that day in hospital. Concerns included that the implanted valve was considered defective by the operating surgeon, although an independent review did not identify a defect.
Medicines and Healthcare products Regulatory Agency
Beryl Varcoe fell or collapsed in her bedroom and repeatedly pressed her community alarm pendant, but the alarm did not activate because her bedroom was outside the base unit’s radio range. She remained on the floor until the following day, developed pneumonia and chest sepsis, and died in hospital on 21 April 2016. The principal concern was that alarms installed or upgraded without thorough range testing may not function throughout clients’ homes, potentially placing other service users at risk.
Elmbridge Borough Council
Margaret Elizabeth Conway, aged 68, was admitted to Pinderfields Hospital with diarrhoea, acute kidney injury and pancolitis after being transferred from Fieldhead Hospital. She suffered a cardiac arrest and died at 0110 hours on 3 September 2016; the inquest recorded natural causes, including acute myocardial infarction and acute severe colitis. The substantive concerns related to the challenges of transferring and caring for patients with both serious mental and physical health problems across geographically and operationally separate services.
Mid Yorkshire Teaching NHS TrustSouth West Yorkshire Partnership Teaching NHS Foundation Trust
Rayan Ahmed, a premature baby cared for in a special care unit, collapsed on 6 July 2016 after his deteriorating condition went unrecognised for 1 hour and 5 minutes. He suffered an unsurvivable catastrophic brain injury and died on 9 July 2016. The principal concern was that nurses covering breaks cared for babies they knew nothing about, with inadequate handover arrangements identified as an issue.
Bristol NHS Foundation Trust
Daniel Gary Dunkley was found hanging in his cell at H.M.P. Woodhill on 29 July 2016 and subsequently died in hospital on 2 August 2016. Three referrals for a full mental health assessment had been made before his death, but none took place; the report identified concerns about the assessment process and the failure to notify the relevant unit or Mr Dunkley about an assessment scheduled for the morning he was found.
Woodhill Prison
Ida Jean Toole suffered an unwitnessed fall at Water Hall Care Centre on 10 January 2017, sustaining a head injury, and died at Milton Keynes Hospital on 14 January 2017. The concern was that, despite being assessed as at high risk of falling, she did not have a sensor mat alongside her bed because she had mental capacity, and the policy for providing sensor mats to high-risk residents required urgent review.
Excelcare Holdings Limited
Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.
University Hospitals Birmingham NHS Foundation Trust
Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.
Swansea Bay University Local Health BoardWelsh Ambulance Services NHS TrustAccount
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